Yap and colleagues1 suggest that China's labor camps for drug users
present an opportunity to implement universal 'test and treat' programs.
They contend that such a step would be consistent with 'humanitarian'
principles endorsed by The Global Fund and the World Bank.

Their recommendation is surprising and troubling. The paper cited to
support this position (which we co-authored) is not in fact a call to
scale up HIV treatment in drug detention centers. Rather, it summarizes
the emerging policy consensus among UN agencies and bilateral and
international aid agencies that drug detention centers undermine the fight
against HIV and should be closed.2

The authors make no mention that The Global Fund board recently
adopted a policy explicitly refusing to fund programs in such facilities
(in China and elsewhere).3 They (and other donors) have taken this
position because they recognize that abuses in such centers are routine
and that donors have little ability to ensure independent oversight of
their funds or programmes.4

Since 2008, Human Rights Watch has conducted research into compulsory
drug detention centers in China and Southeast Asia.5 We have found a wide
range of severe human rights abuses, including, in China, the use of HIV
tests, according to one guard "to know which female inmates they could
sleep with without using a condom."6

Yap and colleagues' recommendations for universal testing and
treatment are intended, no doubt, to protect the health and well-being of
those detained. Yet, their research failed to ask the right questions and
consequently prescribes the wrong medicine. Expanded HIV treatment would
aid some concerns of some detainees. Closing these centers down, in line
with the joint views of 12 UN agencies, would advance both public health
and human rights.7

The use of recreational drugs used in sexual contexts by MSM
(referred to in many developed countries as "ChemSex") is of increasing
public health concern; it would be helpful if the abstract was ammended to
include which recreational drugs were being used by the cohort in this
study.

The audit by Clarke et al of 106 patients provides a useful estimate
of the percentage of anogenital warts among GUM clinic attenders that the
patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure
to examine these patients may have accounted for a considerable proportion
of the reduction in anogenital warts diagnoses in GUM seen in England
between 2008 and 2012, of 8% among males and females of all ages[2]. In
our detailed ecological analysis of the declines in anogenital warts
diagnoses in GUM clinics[3], we considered changes in diagnosis and
reporting practices as possible explanatory factors. As far as we were
aware, such changes would likely have affected all GUM clinic attenders,
males and females, of all ages. Decreases, however, have not been seen for
all. We have seen declines of over 20% among young women (under 20years),
smaller declines among young men, and level or increasing rates in older
males and females[2-4]. We have also seen similar declines in diagnosis
made by GPs[3]. This pattern is harder to explain by fewer patients being
diagnosed via examination in GUM, but could be explained by cross-
protection from bivalent HPV vaccination. We found a significant
association between observed declines and estimated HPV vaccination
coverage among young women[3,4]. If Clarke et al, or others, have data
showing that the effect of changes in diagnosis and/or reporting practices
in GUM and GP since 2008 differ by sex and age, this could provide an
alternative explanation for the decreases we have seen in anogenital warts
diagnoses in England.

In South Africa, a country that has battled with the HIV and TB co-
epidemic for more than two decades, STI management has received little
attention. We were delighted to read the article by Lurie et al, which
highlights the high burden of STI syndromes in people living with HIV, in
particular, in the period before ART initiation. While we concur with the
authors' conclusions that systematic STI testing and treatment is
warranted in HIV care programmes, the epidemiological data presented leave
several unanswered questions.

There are major problems with reliance on syndromic management,
particularly with the syndrome of vaginal discharge. STI symptoms poorly
correlate with laboratory diagnoses, illustrated by gonorrhoea and
chlamydia, which are mostly asymptomatic in women. Studies at the Centre
for the AIDS Programme of Research in South Africa (CAPRISA) have shown a
high prevalence of laboratory-diagnosed STIs in women at the time of acute
HIV infection. Further analysis showed that clinical assessment alone
missed 88% of laboratory-diagnosed STIs and 66% received unnecessary
treatment [1].

Furthermore, the commonest cause of vaginal discharge is bacterial
vaginosis (BV), an infection that is associated with sex, but does not
appear to be sexually transmitted. We have found that over 50% of women
had BV at HIV diagnosis which is often persistent [1]. Lurie et al omit
mentioning BV, perhaps misclassifying some of their findings.

While the authors' results are intriguing, a potential mechanism for
the reduction of syndromic STIs on ART is missing. One could hypothesize
that immunosuppression may increase the susceptibility and ability to
clear STIs and BV. However, in this study the reduction in incidence was
independent of CD4 count, in fact, the opposite was true, that a higher
CD4 count was associated with more syndromic STI diagnoses. Alternative
mechanisms namely behavioural change and length of clinical follow-up may
have had a greater impact on the reduction of syndromic STI incidence than
improvement in CD4 count in response to ART.

We hope, that the findings by Lurie et al and the following debate
will contribute to the long overdue implementation of STI testing and
treatment policies in South Africa.

Yours sincerely,

Nigel Garrett and Adrian Mindel
Centre for the AIDS Programme of Research in South Africa (CAPRISA)

The highlights of a strategy endorsed by the World Health
Organization (WHO) in 2010 for Sexually Transmitted Infections (STI)
screening, testing and early initiating into treatment (TnT) to Men that
have Sex with Men (MSM) and transgender people are discussed by Cohen et
al. in their editorial letter entitled "WHO guidelines for HIV/STI
prevention and care among MSM and transgender people: implications for
policy and practice" (1,2). In the same line as WHO, the authors call for
improved access to STI screening services for people in low and middle-
income settings regardless of their sexual identity, sexual orientation or
their cultural and socioeconomic characteristics (1,2) Due to the higher
prevalence of STI among these vulnerable groups, compared to the general
population, the uptake of this guideline is recommended to prevent the
transmission of STI and ensure that sexual minorities enjoy their right to
access quality provision of STI healthcare (1,2).

The advantages of this strategy are understandable. This, regardless
of the scarcity of data on the cost-effectiveness, cost-benefit and impact
on community incidence of STI of routine TnT to asymptomatic MSM and
transgender people that the WHO recommends (1). As the raison d'etre of a
public health approach being informed by the evidence seems disregarded,
in this letter we intend to highlight some gendered aspects that also
derive from the WHO guideline and that, in our opinion, Cohen et al. may
have given the same relevance as they had given to the WHO-endorsed TnT
strategy.

STI screening is a secondary prevention strategy. In the scenario we
are discussing, it may be assumed that all MSM and transgender people may
eventually engage in sexual risky behaviours and, as consequence, be
infected with an STI. Hence, the recommendation to screen those targets
populations for STI even if asymptomatic. The pitfall of this
recommendation is that these vulnerable groups may end up dealing with
healthcare providers with prejudices towards them.
The first assumption healthcare providers should have in mind is that
these groups adhere to key messages on how to lead a healthy sexual life.
Hence, Routine STI screening should not be the first step in the cascade
to prevent, detect and treat STI. It can be ventured that STI TnT approach
might result being less cost-effective, potentially more stigmatizing,
and, more distanct from the goal of equity that the traditional primary
prevention strategies hold (2,4).

On the other hand, women are not listed among the beneficiaries of
this prevention strategy. The significance of understanding the
motivations and other factors contributing to sexual risk taking among MSM
that also have sexual intercourse with Women (MSMW) have been highlighted
elsewhere (5,6,7). It must be acknowledged that in many low and middle-
income countries, in order to fulfil with social expectations, many MSM
may also engage, in an casual or in a permanent manner, in heterosexual
relationships (7). To effectively reduce the community-level prevalence of
STI, all asymptomatic women should also be targeted as beneficiaries of
this TnT. In a context where cultural taboos and social stigma,
judgemental attitudes from health workers towards sexual minorities,
repressive policies, and anti-gay legislation, it is very unlikely that
their MSMW might disclose to their female partners or their healthcare
providers that they occasionally engage in unprotected same-sex sexual
intercourse.

Fear to being stigmatized acts as a driving force that leads MSM to
becoming MSMW, keeping their sexual orientation hidden, and hindering them
from accessing and demanding STI healthcare. Acknowledging this leads us
to another worrisome issue that should not be neglected from the umbrella
of responsibilities that lie within the scope of the public health arena;
how many countries with pandemic HIV/AIDS infection figures have actually
decriminalized homosexuality in the last decade? According to the
International Lesbian and Gay Association Report, there were 76 countries
prosecuting people because of their sexual orientation as recent as in
2010. Eleven countries still include death penalty for homosexuals in
their penal code (8). To effectively inform and carry out any health
promotion campaign targeting MSM and transgender people, beyond advocating
for the implementation of massive TnT strategies that capitalize the
potential of new nucleid acid amplification testing technologies, the
international community should move the focus to advocate for low and
middle-income countries? governments to abolish their pre-colonial 'anti-
sodomy laws', build the capacity of their healthcare providers to better
address the health needs of MSM and transgender people, and raise
awareness among the general population to respect the sexual rights of the
most vulnerable ones (9,10).

A behavioural change approach, with the aim to promote adoption of
safer sexual practices and an active demand of HIV/STI healthcare
services, needs to be effectively integrated with any proposed TnT
strategy. Health promotion is a basic public health tool that we find that
it is not referred to in Cohen et al. missive. There is scientific
evidence that behavioural change-based education, community awareness and
advocacy approaches targeting sexual minorities may have a positive impact
-even in budget-constrained settings- in terms of adoption of safer sexual
practices with the ultimate goal to reduce incidence of HIV/STI (11). Why
for Cohen et al. the cornerstone of the cascade of "solutions" to the high
prevalence of STI may lie in targeted routine TnT when there is evidence
on the benefits primary prevention strategies?.

From a primary prevention point of view, other approaches should be
recommended. A public health approach to tackle HIV/STI is necessarily
gendered. The structural gender system has to be taken into account,
including in low and middle-income countries, when designing and endorsing
these types of prevention strategies. It is crucial to understand how
gender constructions are determinant in populations adopting sexual risk
practices, in impeding or facilitating their access to HIV/STI diagnostic
and treatment services, and in influencing government and institutional
policy and decision making processes (12). To have a more comprehensive
picture to inform approaches such as the STI TnT discussed in this letter,
it can be suggested that other subjects such as "masculinities,
transactional sex, infrastructural deficits in health and education (at
all levels), fragile states and global governance" (13) should be studied
and that sexual risk practices should be tackled in a broader context in
which gender equity is pursued and stigma and discrimination are
combatted.

Responding to the editorial by Miller et al regarding the methodology of
our study , we would challenge the assessment of the Zelen design as
representing a form of 'deception'. Zelen design is employed to generate
real life responses to help understand the translation challenges of
introducing any similar or modified intervention across a whole area.

When general practices involved in our study were later informed of their
participation none expressed concern. Qualitative work undertaken with
these practices since the study has further confirmed they were supportive
of the study design selected, and stated it reduced bias. Chlamydia data
from general practice are routinely collected and published in England.

The editorial correctly identifies that levels of chlamydia screening
within general practices in England is currently low. Viewed in this
context, the 60% uptake generated by this intervention is significant. In
terms of the increases in testing observed during and after the
intervention period, our results were reported without inflation. Further,
while the results from the intervention may be modest, repeated on a
national scale a substantial increase in overall testing rates would be
observed.

The National Chlamydia Screening Programme identifies general practice as
an important venue through which opportunistic screening can be offered to
young adults. We also know the most common form of contact young people
have with medical services is with their GP. The results generated through
our intervention represent a positive development in our understanding of
how to increase screening in this setting. By engaging GPs in chlamydia
screening, opportunities are created to discuss wider sexual health issues
with young people, in a familiar and trusted surrounding.

We concur with Miller et al that changing practitioner behaviour is
challenging. General practice is a complex environment where practitioner
behaviour is subject to the influence of previous education and training,
practice managers and partners, competing targets, and other priorities
determined by the NHS. Other further research has shown that sustained
support is important to maintain the impact of any multifaceted
intervention, , and therefore Public Health England is continuing to
provide such support. However, further research into how to sustain and
maximise the impact of interventions to improve the sexual health service
delivered in primary care would also be beneficial.

Conflict of Interest:

All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare that '(1) CM, ER, AH, LW, RC, IS, EO, SK, AC have support from the Public Health
England for the submitted work. Dr Cliodna McNulty leads the Public Health England Primary Care Unit that has an ongoing programme
of work aimed at improving the management of infectious disease in primary care. Public Health England leads the National
Chlamydia Screening Programme in England.

Phillips and colleagues found a third of in-patients had HIV tests
following implementation of a routine HIV testing policy at Croydon
University Hospital1. We recently found similar rates of HIV testing in
young women in the community in our medical student research projects. In
line with the 2013 Framework for Sexual Health Improvement's "three
specific indicators for sexual health" 2, we investigated reported uptake
of HIV testing, chlamydia testing and long acting reversible contraception
(LARC) in young women attending a further education college and a
university in London.

In September 2013 consecutive women in common room areas were invited
to complete a confidential questionnaire on sexual health. The response
rate among women at Lambeth College was 78% (77/99). The mean age of
responders was 18 years (range 16-24), and 43% described themselves as
being of black ethnicity, 19% white, and 38% of other ethnicity. Of the 39
(51%) women who said they were sexually active, 51% (20/39) had been
tested for HIV in the past year and 78% (28/36) for chlamydia. A third
(13/39) were currently using LARC (implant n=10, injection n=3).

The response rate among women at London Southbank University was 92%
(79/86). The mean age of responders was 21 years (range 18-25) and 38%
were from ethnic minorities. In the past year, 32% (25/79) had been tested
for HIV and 34% (26/77) for chlamydia. Only 5% (4/79) reported the use of
LARC in the past year, all of these being the implant.
We agree with Phillips and colleagues that late diagnosis of HIV is a
major public health problem. The recent Natsal report found that 29% of
women but only 14% of men aged 16-24 years reported being tested for HIV
in the past 5 years 3. Although rates of HIV testing in sexually active,
multiethnic young women in our study were encouraging, it is also crucial
to promote HIV testing in young men.

Anne Tear and Jessica Herbert
3rd year Medical Students
Pippa Oakeshott
Reader in General Practice
Population Health Sciences and Education, St George's, University of
London
Correspondence: m1000382@sgul.ac.uk, m1101507@sgul.ac.uk
Acknowledgement
We thank students and staff at Lambeth College and London Southbank
University.

Trichomonas Vaginalis (TV) is frequently described as being
associated with pre-term delivery and low birth weight - and was again by
Professor Hillier in her editorial in her (unreferenced) introductory
paragraph. As far as I can ascertain, this association appears to be based
on published evidence from the 80s and 90s.

Is it possible, given the more recent understanding of a link between
TV and poverty, that these 20 year old studies were confounded?

There is conflicting evidence as to whether the use of metronidazole
is itself associated with worse birth outcomes1,2 and so it is important
to have a full understanding of the role of TV.

In global terms I work and teach in a setting with a low prevalence
of HIV. Can anyone help me find reasonably strong evidence that TV is
other than a harmless commensal for those of my patients who are
asymptomatic?

We very much appreciate the letter that Dr Haghdoost and colleagues
wrote in relation to some of the issues outlined in our paper HIV
surveillance in MENA: recent developments and results and, in addition,
described some more recent developments in HIV surveillance in Iran.

We would like to reflect on several issues that they raised.

Our paper states that Djibouti, Iran, Morocco and Pakistan can be
classified as having fully functioning HIV surveillance systems as trends
in HIV prevalence in these countries can be assessed over time for certain
population sub-groups. Surveillance systems in these countries have a
sufficient quantity and quality of the data that can be used to guide the
programmatic responses. We also mentioned other nine countries that have
partially functioning HIV surveillance systems.

As described in the Methods section of our paper, the assessment of
the quality of HIV surveillance systems was based on the questionnaire
sent to National AIDS Programmes (NAPs) of the countries of the WHO
Eastern Mediterranean Region (EMR) in 2009, 2010 and 2011, and not on the
data presented in the paper by Garcia Calleja et al published in Sexually
Transmitted Infections in 2010. As described in our paper, to assess the
quality of HIV surveillance systems we adapted a method developed by WHO
and UNAIDS.123

As one of the limitations, we outlined that data were provided by the
NAPs, which might have missed data sources collected by other agencies
that Haghodoost et al. mention, such as surveys in partners of IDUs.
However, as planning of surveillance and programmatic responses is lead by
the NAPs, we think that collecting data from NAPs gives an appropriate
insight into the type and quality of data that the countries use for
planning and evaluating the national HIV response. We are aware that many
studies might be undertaken in the EMR, but their results are not
disseminated, and this is particularly the case with studies done in
groups at higher risk of HIV that are heavily stigmatized.

In relation to some other issues that the colleagues raised, surveys
using respondent-driven sampling were done in many other countries in the
Region (some of these are referenced in the paper) as well as Mode of
Transmission studies.4

We have not reflected on the reasons for the improvements in HIV
surveillance in North Africa and the Middle East, but we believe this has
been due to greater availability of funding provided by the Global Fund to
Fight AIDS, Tuberculosis and Malaria and capacity building efforts of
numerous international and national agencies.

We agree with Dr Haghdoost and the colleagues that there are
substantial improvements in HIV surveillance in Iran though significant
challenges remain in bridging the gaps that the system still has. One of
them is certainly in conducting studies on HIV and sexually transmitted
infections in MSM and transgendered individuals, which due to prevailing
stigmatization are still lacking throughout the Region.

We very much enjoyed reading Dr. Bozicevic's paper about the recent
developments in HIV Surveillance in MENA in a recent issue of your journal
[1]. Some topics discussed in that paper concern us and we would like to
share a few opinions about the current HIV surveillance system in Iran and
its recent advances.
In the paper it is stated that only two countries in the region (Morocco
and Sudan) have a partially functioning HIV surveillance; however, we
assume this is based on the data presented in a study conducted in 2009
[2] and at present, Iran has also a somewhat functioning HIV surveillance
system. For example, Iran has done a pretty fine job in controlling the
HIV infection among IDUs and monitoring the epidemic trend in pregnant
women [3]. Iran has been also conducting biannual bio-behavioral surveys
among IDUs, FSWs, IDU partners, and prisoners [3]. More recently, size
estimation programs have been introduced to the system and we have
conducted size estimation studies in estimating the size of at risk
populations [4]. On top of the above, Iran is one the only countries in
the region that has conducted Respondent Driven Sampling as well as Mode
of Transmission studies [3, 5]. What is more, the number of HIV/AIDS
related publications in Iran (in PubMed database) has doubled in a five-
year period which is also an evidence of improvement of the system [6].
We think a number of reasons may have contributed to this progress. The
role of the Regional Knowledge Hubs in HIV/AIDS Surveillance in educating
healthcare providers and researchers as well as health policy makers
cannot be ignored [7]. These educations have been given through national
and international workshops and sending out educational packages to
different policy makers, from members of the parliament to those in the
presidential office. We assume highlighting the burden of HIV/AIDS in the
upcoming years has been successful in drawing policy makers' attention to
the seriousness of the HIV epidemic across the country in a way that
controlling HIV/AIDS throughout the country was a serious concern in the
recent presidential debates.
Despite all the achievements in addressing the HIV epidemic, there is
still a lot to be done and the current system still suffers to a
considerable extent. For example, likewise most countries in the region,
MSM and transgendered populations have long been overlooked in the HIV
surveillance system; ignorance mainly originated from the stigma
surrounding such populations. We think one of the main challenges to be
overcome is the pitfalls in the case finding and reporting system of Iran.
The sensitivity of case finding in Iran is low and following up the HIV
patients and assessing their adherence to therapy is a major challenge in
front of healthcare providers [5, 8]. Although the case reporting system
is not fully functioning, a national computer-based is being launched in
the country that opens a window of hope in fixing the defects in the
current reporting system. The Ministry of Health is really optimistic
about this system; however, its effectiveness is yet to be evaluated.